HIV Illness Meanings and Collaborative Healing Strategies in South Africa

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HIV Illness Meanings andCollaborative Healing Strategies inSouth AfricaElizabeth Mills a ba University of Cape Town ,b Development Studies at the University of Cambridge , E-mail:Published online: 11 Aug 2008.

To cite this article: Elizabeth Mills (2005) HIV Illness Meanings and Collaborative HealingStrategies in South Africa, Social Dynamics: A journal of African studies, 31:2, 126-160, DOI:10.1080/02533950508628711

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Social Dynamics 31:2 (2005): 126-160

HIV Illness Meanings and CollaborativeHealing Strategies in South Africa1

Elizabeth Mills

AbstractTraditional health care practices were fo rmally recognised and advocated bythe World Health Organisation (WHO) in 1978. The implications of theWHO 's directive have been diverse, and have shifted over the subsequentthree decades of international health care. Similarly, the landscape of diseaseand illness, within and bey ond South Afric a, has been significantly infl uencedby the burgeoning international and regional HI V-epidemic. In South Africathe move to democracy was coupled with a decentralisation of the NationalHealth System (NHS), increasing rates of HI V-infection, and a political desireto recast traditional healing as an Af rican cultural practice deserving ofstateendorsement. This paper considers the multiple illness meanings andtreatment strategies employed by HIV-positive people and traditional healersliving in Cape Town, South Africa. In order to offe r an understanding oftreatment strategies that move between the biomedical and traditionalhealing, this paper draws on the distinction between the psychosocial aspectsof illness and the biological disorder ofdisease. The fi rst section of the paperpresents a case study of an HIV-positive woman 's experiences of the illnessand the disease of HIV, and explores her concomitant health care strategiesbased on her shifting conceptions and experiences of HIV The subsequentsection moves into a detailed analysis of interviews conducted with a sampleof traditional healers. This section highlights the traditional healers 'overlapping and also divergent views on the causation and treatment ofHIVand AIDS-related illnesses amongst their HI V-positive clientele. Finally, thispap er places traditional healing practices and practitioners within the contextof South Africa's NHS in order to suggest some of the potential benefits andlimitations around collaboration between biomedical and traditional healthcare paradigms.

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Elizabeth Mills 127

IntroductionThe majority of people living in resource-poor settings in Africa depend ontraditional healers for psychosocial counseling and health care. In SouthAfrica , it has been estimated that over 300,000 traditional healers ply theirtrade, that is, approximately fifteen times more than the number of medicalpractitioners (Liddell et al., 2005) . Given the current AIDS epidemic, inwhich over five million people have become HIV-positive in South Africa(UNAIDS/WHO, 2005), there is a strong argument for mobili sing bothbiomedical and traditional health practitioners to address the complexpsycho social and physical nature of HIV-infection and AIDS-related illnesses.

The World Health Organisation initially marked the importance offormally recognising traditional healers as public health care providers at aninternational level in 1978 at the Alma Ata International Conference onPrimary Health Care. In 2002 the WHO renewed this commitment toincreasing the role of traditional healers in primary health care provision; thiscommitment was also taken up by the African Union through the declarationof the decade of African Traditional Medicine from 200 I to 20 I0(www.africa-union.org). The urgency behind the WHO's call for the inclusionof traditional healers in public health care in 1978 differs to that whichprompted the latter call by the African Union in 2001 :

Earlie r, the inclusion was motivated by the problem s of shortage of personnel inthe modern sector, the self-reliant character of traditional medicine, its culturalsensitivity and its therapeutic value . Presently, while the above reasons remainvalid , the increasing social devastations by the AIDS pandemic in poorlyperforming health care systems confirm the need of involving the traditionalhealth sector. (Kaboru et al., 2005 : 2).

The debate on intersectoral collaboration between biomedical andtraditional healers mainly has focussed on the risks and feasibility associatedwith collaboration from a policy (top-down) perspective; frequently critiquescentred on the pros and cons of including traditional healers in the formalhealth care system (see Green, 1994; Kaboru et al., 2005). Irrespective ofwhether collaboration is feasible or even desirable, it is important to gain abetter understanding of the way that traditional healers and their clients movebetween the different healing paradigms. This paper takes a few stepstowards extending our knowledge of this issue by means of an ethnographicstudy of the way that traditional healers are responding to HIV/AIDS and theway that HIV positive people may be negotiating their way betweenbiomedical and traditional healing strategies.

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128 HIV Illness Meanings and Collaborative Healing Strategies

The first section presents a case study of an HIV-positive woman'shealth seeking behaviour, which includes drawing on healing strategies thatrange from using traditional medicine, allopathic drugs and spiritual healing.This case study underlines Kleinman's (1988) distinction between thepsychosocial aspects of illness and the brute materiality of physical disorder,namely disease, arguing therefore that different health care options fulfilidiosyncratic and differing needs of HIV-positive people. Following thisconsideration of the fluid nature of health seeking behaviour, the subsequentsection explores a range of illness meanings and . treatment perspectives heldby a sample of traditional healers who work in the Western Cape.

As demonstrated through the case study and qualitative research withtraditional healers , it can be seen that traditional healers adopt a range ofhealing practices and sometimes encourage their clients to use a combinationof biomedical and traditional treatments that would best serve their variouspsychosocial and physical needs. The final section of this paper explores theattitudes of traditional healers towards collaboration with biomedicalpractitioners in the area of HIV/AIDS prevention and treatment.

The research that forms the basi s of this paper was conductedbetween May and August 2005 amongst people living in informal shacksettlements on the border of Cape Town's central business district.' Theauthor and assistant researcher, Busi Magazi , used semi-structured informalin-depth interviews in order to explore pre-determined themes and,importantly, to allow space for new themes to emerge in the course of theinterview. Access to traditional healers was by no means straightforward, andcarefully formulated information and consent forms were distributed in orderto allay some of the traditional healers' concerns that the researchers wereacting on behalf of an antagonistic government wishing to discredit theirwork. Fortunately, however, in many cases, following the interview, thetraditional healer would suggest a colleague or friend who would be willing tocollaborate with the researchers and we would then move on to set up ameeting with the next traditional healer. This research does not aim torepresent the views of all traditional healers living in South Africa, but to putforward , and make sense of, the perspectives of those traditional healersinvolved in this research project.

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A Contentious TermThe term ' traditional hea ling' falls into a terrain of contested discourses, andat time s has conjured up image s of ancient healing methods rooted in aparticular history and place . Thi s paper concurs with Wreford 's (2005:3)assertion that it is important to understand that traditional healers are not fixedrelics of Africa's history, but actors in a comp lex and dynamic world in whichthey find ways to thrive and adapt to constant change. To make matters morecomplex, traditional healers can occupy multiple social roles . As Greenstate s:

traditional healers arc priests, religious ritual specialists, family and comm unitytherapists. moral and social philosophers, teachers, visionaries, empiricalscientists, and perhaps political leaders in addition to being healers in the morerestricted Western sense ( 1994: 36).

Traditional healers should thus not be understood as forming and stemmingfrom a united and generic body of hea ling practices and beliefs.

Furthermore, as Mary Douglas asserts , science and (bio)medicine also' can be seen as cosmologies: as systems of natural symbols which we todaycan make sense of our existence in the world ' (in Jones , 2004: 705) . Thispaper demon strates how peop le are able to move between, and often straddle,multiple treatment cosmologies . Worki ng with bounded dichotomies inwhich ' traditional' and 'biomedical' know ledge systems are rooted in ' local'or ' global' epistemologies · respectively is thus misleading. Thi s paperrecognises the problematic use of the term 'traditional healing' whereby thesefalse dichotomies are reinforced, and it works actively to cha llenge theseperceptions by illustrating the multiple ways in which traditional healers andtheir patients have accommodated and responded to the shifting terrain ofhealth care in South Africa.

Illness Meanings and Healing Strategies: A CaseStudy

In the human context of illness, experience is created out of the dialecticbetween cultural category and personal signification on the one side, and thebrute materiali ty of disordered biologic al processes on the other. (Kleinman,1988: 55).

The way in which illness is understood and experienced, whether it is throughpersonal signification, cultural category, biological disorder or a combinationof the abo ve, informs the kind of treatment that is sought to hea l the illness.

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130 HI V Illness Meanings and Collaborative Healing Strategies

However, the way in which one understands illness is itse lf informed bynum erou s factors, not least public policy, the media and epistemologies drawnon by health practitioners to support their various forms of health carepractices. Therefore, the epistemology that informs and supports a particularform of treatment will in turn reproduce, or challenge the individual' sunderstanding of his or her illness, continuing or reconstituting the cycle.

Kleinman ( 1998) argues that illness should be understood as thepsycho social and cultura l aspect of disease . The differentiation betweenillness and disease is significant in this discussion becau se it challengesbiomedical discour se to move beyond pathologising the indiv idual to a deeperunderstanding of the complex factors that coalesce to create the experience ofillness . In turn , this ca lls for a redefinition of 'suffering ' as an interpersonaland intersubjecti ve experience that extends beyond the individual into theirsocial environment. In line with this notion of ' social suffering', the chronicillnes s of an individual can be understood as influencing and influenced by theindi vidual' s social environment, thus possessing a soc ial history. Both thebiological disease and the psycho social illness of HIV play out in variousways for HIV-positive people and their social environments. Networks oftreatment options are drawn on, as demonstrated in the vignette below, inorder to access both physical health care and psychosocial care at var iousstages of the disease. As demonstrated below, ontologica l beliefs around HIVaffect the way in which it is exp erienced and treated by the HIV-positiveindividual. As a result, numerous sources of health care are drawn on in orderto treat different aspects of HIV, as both an illness and a disease.

A Case Study of Nana 's Treatment Strategies

Nana is 28 years old , and lives in Khayelit sha , Cape Town 's largest informalsett lement. She has a one-year old child, and because she works as a full timeoffice ass istant, she leaves the child in the care of her sister durin g the week.In March 200 I Nana tested positive for HIV, and started takin g antiretroviraltreatment in February 2002. Unlike most other unemplo yed people, she wasable to access antiretro viral therapy by participating in the pilot antiretroviraltreatment project oper ated by Medecins Sans Fronti eres and the Western CapeProvincial Gov ernment. During the time between her positive diagnosis andgoing on treatment, recurring skin rashes and other ailments concerned herfamily and, unaware of her HIV status, they enco uraged her to see anIgquirha (isiXhosa name for isangoma) in order to ascertain why she was' always so sick'. Although Nana knew that she was HIV-positive, she also

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felt that there might be a myst ica l reason why she had con tracted HIV, andcontinue d to suffer from a painful skin rash and other recurring ailments. Inthe eleven months between March 200 1 and February 2002, Nana visited atotal of three traditional healers in order to ascerta in the metaphysicalaetio logy and necessary treatment of her HIV-serop ositivity and recurringillnesses.

Eac h of the tradi tiona l healers confir med Na na's belief that herillnesses were not simply a cause of a physical ' disorder' : Nana had beenbewitched . The traditional heal ers cla imed that a person , or group of people,in Na na's co mmunity we re jealous of her because she was young andeducated. The third and main trad itiona l hea ler that Nana consulted said thatNana's main complaint, a serio us skin rash, was a result of having beencurse d by a witchdoc tor to be a reptile, like a frog or a sna ke. Her skin, Nanasaid, was peelin g in a similar way to that of a snake shedding it' s skin.Hend erson suggests that the skin is deeply symbo lic of the body's enve lope,and when it eru pts or is no longer smooth, highl ight s the 'failure of the bodiesto hold , to maintain a modicum of cohere nce ' which in turn ' is ex terna lisedand mirrors (the) experience of collapsing socia lity' (2004: 5). Nana'sdiagno sis, and Henderson' s descr iption of the symbolic nature of the humanbody' s skin, highl ight s Bergland ' s contention that illness is not simply relatedto physical disease but to social disruption and conflict ; in turn, health is notsimply a state of physical well-bei ng but also one in whic h the individualmoves in a soc ial context free from malevolent forces or social conflict(1976).

Significantly, Nana did not inform any of the tradit ional healers thatshe was HIV-posit ive; she felt that they should be ab le to tell her if she wasindeed HIV-positi ve. On the one hand Nana wanted to test the proficiency ofthe traditional healers she visited, and on the other hand Nana felt ambiguousabout her HIV-status and partly believed that both its symptoms and the virusitself co uld be addressed by trad itional healers. When Nana discovered thatshe was HIV-positive she had a limited unders tanding of the virus but a clearunderstanding of the potent ial stigma she would be expose d to if she disclosedher status (see Mills, 2004; Ratel e and Shefer, 2002 ). The traditional healers 'diagnosis of bewitchment due to jealousy mitigated , to an extent, Nana'sdistress at being HIV-positive and concern over its possible socialramifications, like HIV-related stigma :

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If mys tical forces dominate human experience, then believing that these arerational forces brings a sense of order to unfortunate events. (Lidde ll et al.,2005 : 684)

The affirmation that Nana ' s illnesses were a result of someone' sjealousy highlighted positi ve aspects of Nana's life, her professional successand education, rath er than what she felt was a deeply discrediting attribute:her HIV-positive status.

The diagno sis of bewitchment deflected Nana's immediate focus onwhat she might have done in order to contract HIV onto the role that jealousneighbours may have played in makin g her ill. On the one hand , Nana ' smortification at being HIV-positi ve was partially allayed by the trad itionalhealers' diagnosis. On the other hand , however, the diagnosis of bewitchmentcontributed towards social disruption and distrust between Nana and thepeopl e suspected of bewitching her. Nana said that she believed she had beenbewitched, and could understand why people in her community may havebeen jealou s of her because she was beautiful and intelligent. She recall shaving a visceral reaction to the 'evil atmosphere ' of the community in whichshe had been living, and decided to move from her home to a differentlocation once she had recovered from her ' bewitchment'. Nana said that eachof the traditional healers were careful not to disclose any names of the peoplerespon sible for bewitching her. Although this protected the ident ity ofindividuals, the diagnosis of bewitchment resulted in Nana 's genera l mistru stof her community, which indicates a possible negati ve impact of diagnosesthat label people, albeit generally, within the sick individual ' s socialenvironment as malevolent.

In considering Nana's range of treatment choices, this paper draws onGreen ' s work ( 1994) in which he argues that a lexicon of proximate andultimate illness causes encompass and stimulate multiple ae tiologies andhealing options. The notion of ' proximate illness causes' relate to the physicalsymptoms of the disease, whereas ' ultimate illness causes' are con sidered tolie in the mystical and spiritual rea lm. For exa mple, Green ( 1994) explainsthat a Swazi mother will concede that her sick child has diarrh oea becauseflies settled on its food (proximate cause) but will also want to ascertain whowas responsible for sending the flies to make her child ill (ultimate cause).Both the proximate and ultimate causes of illness require treatment: theproximate cause can be treated by medi cal personnel whereas treatment forultim ate causes of illness, which lies primarily in the spiritual and mystical

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domain, is sought from traditional healers or diviners (Green, 1994; Liddell etal., 2005).

Nana initially consulted a traditional healer because she wanted toestablish the ultimate cause of her recurring skin rash. Her family supportedthis decision because they felt that the recurring nature of her ailment wasinexplicable and unsuited to biomedical intervention. Each of the threetraditional healers attempted to treat both the 'bewitchment' itself, the' ultimate ' cause, as well as the physical manifestation of the 'bewitchment' ,which took the form of her skin rash . The third traditional healer that Nanavisited performed an extensive cleansing ritual , lasting seven days , in order toaddress Nana 's bewitchment. As part of her treatment with this traditionalhealer, Nana moved into the traditional healer's home and spent the majorityof the day inhaling steam infused with particular medicine. As part of the finalclimax in Nana's treatment, she was taken into ' the bush' in order to banishthe curse that she had been placed under.

The traditional healer lived in a shack settlement in Cape Town awayfrom large areas of vegetation, and therefore, ' the bush' that Nana refers towas, in reality, a small plot of trees in the vicinity of the traditional healer'shouse. Once in the bush, Nana was told to take off all of her clothes. Thetraditional healer had pre-selected a chicken, which had particular symbolicsignificance in counter-acting the malevolence of the curse that Nana wasunder. The chicken was killed by slitting its throat , and the traditional healercollected the chicken's blood in a small container. Nana was instructed todrink a mixture of the chicken's blood with brandy. After Nana had drunk theblood and brandy mixture, the traditional healer explained that death had beenput inside her body, and that in order to release the death, she needed to cutopen the black spots on Nana's skin . As Nana told me about this procedure,she pointed to the freckles on my arm , saying that they were the equi valent ofthe black spots on her body. Nana 's black spot s were cut open with a razor ,and the 'bad blood ' was drained out of them. The traditional healer proceededto rub a mixture of medicine into the wounds in order to prevent any ' evil ordeath ' from re-entering them. Thereafter, Nana was instructed to place thechicken in the ground and to address the chicken as if it was the personresponsible for her bewitchment, saying 'My name is Nana, and you muststop hurting me.' In this way, the death of the chicken symbolised thetermination of Nana's bewitchment.

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Thi s ritual, as described by Nana, represents a complex healingcos mology in which soc ial affa irs are represented and managed through ritualin order to reinstate social and individual health (see Bolle, 1983; van Baal,1976). The presence of 'evil' in the 'bad blood ' beneath Nana's dark spotsechoes medical anthropological research into the symbolic interpretations ofthe body and its fluids; Benedict Ingstad, for exa mple, describes Tswanamedical bel iefs that operate on two levels of causality, namely the origin andimmediate cause of illness ( 1990). Blood, which is seen as one of the mostcritical life esse nces, is used frequently in Tswana aetiology in order toexplain the immediate cause of sickness . In turn , cleansing of ' dirty blood ' isa concomitant aspect of the healing of sickness . The death of the chickenrepresents the symbolic death of the Nana' s ' bewitchment' and thecommencement of her healing. This ritual affords Nana an opportunity toaddress the perpetrators, albei t figurati vely, and to reach a sense of closureand resolution. Nana ' s descript ion of the ritual and its symbolic valuesugges ts that it occupied the dual space of resolving and sea ling off (socialand physical ) malignancy and opening up a future of health in Nana 'sphysical body and soc ial environment. Nana return ed to the traditionalhealer ' s home , and was cared for by the traditional healer for a further twodays until she was fit enough to return to her family. After seeing thistraditional healer Nana felt that she was getting better, and she recalls beingpleased with the tradit ional healer' s treatm ent.

However, after a couple of weeks, Nana became even more ill,marked by significant weight loss, than she had been prior to visiting thistraditional healer. With her life in danger, Nana decided to visit a medicaldoctor. She had felt that the traditi onal healer had been effective in address ingthe ' ultimate' cause of her illness, namely the bewitchment , but the ' brutemateriality' of what had developed into AIDS prompted her to seekbiomedic al treatment in order to address the ' proximate' symptoms of herillness.

At this point in Nana' s illness trajectory, she realised that she neededto address the 'brute materiality and disordered biological processes' of beingHIY-positive . In Nana' s mind this was not antithetical to the aetiology thatshe had at first attributed to the symptoms of her disease. In this way, Nana' sexperience confirms Kleinman 's statement that ' experience is created out ofthe dialect ic between cultural category and personal signification on the oneside, and the brute materiality of disordered biological processes on the other. '

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(1988: 55). Nana decided to not only address the illness of HIV, namelybewitchment caused by jealous neighbours, but also the physicalmanifestations of the disease of HIV, in this case, a radically diminished CD4count.

In consultation with a biomedical doctor, Nana decided to takeantiretroviral treatment (ARV). Nana said that the doctor had spent a longtime explaining the causation and treatment of HIV and AIDS-relatedillnesses to her, and that this had allayed her concerns about taking ARVs.Aside from her realisation that ARVs were necessary to improve her health,Nana was influenced by her HIV-positive brother's positive experience oftaking ARVs after he had been seriously ill with AIDS-related illnesses. Athird reason, according to Nana, was that she felt sure that she was going todie , and after trying a range of non-allopathic treatments, she felt that shemight as well try taking ARVs.

Nana's CD4 count increased over time, and she was gradually able torestore her health and re-enter the formal employment market. In 2004 Nanadecided that she wanted to have a child. She explained to me that sheexperienced a large amount of criticism from other HIV-positive people forher decision to become pregnant. This is connected, according to Nana, to twomain reasons. Firstly, she ran the risk of transmitting HIV to a child throughchildbirth, or breastfeeding, and secondly, she may not be able to raise herchild if she died prematurely with AIDS-related illnesses. Despite theseconcerns, Nana explained that it was herright and legitimate desire to have achild. She consulted with her doctor and was told that the ARVs had reducedher viral load to such an extent that the risk of passing on HIV to her childwas extremely low. Her child was born HIV-negative, which Nana attributedto the ARVs , and this played a critical role in Nana's ongoing active supportfor South Africa's antiretroviral roll-out.

This case study highlights the way in which Nana sought out differenthealing strategies in line with her shifting experience of HIV as an illness andas a disease and ties into Engel's (1960 in Viljoen, Panzer, Roos andBodemer, 2003) biopsychosocial model which affirms that

social , biological and psychological factors comprise a complex system ofinteractions which determines the individual 's health and vulnerability, as wellas reactions , to disease . The biopsychosocial model challenged the singledomain approach of the biomedical paradigm. (Viljoen et aI., 2003: 332).

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According to this logic, health , or disease, can be seen as the productof perpetual interactions between each of the above -mentioned factor s.Similarly,

the ons laught on health can therefore be from various entry points or even fromvario us interactions. Interventions can similarly, within obvious limits, beper formed at any of the interacti ng domains or even from a combinat ion ofentry points. (V iljoen et al.. 2003 : 332)

Nana ' s treatment strategies were not understood by Nana to beexclusive or antithetica l to each other, but rather that they were appropriatefor treating different aspects of HIV. Furth ermore , Nana says that her beliefsabout traditional healers fluctuate: 'Sometim es I do and sometimes I don 'tbelie ve in izangoma.' Five years after Nana was first diagnosed with HIV shecontinues to draw on a range of heal ing professionals, like trad itional healers,medi cal doctors and spiritual healers. For example at the time of herinte rviews for this study, Nana and her partner were seeing a spiritual healerin order to strengthen their relation ship. In addition to see ing a spiritua lheal er, Nana has begun to attend church serv ices. She said that she believesher relati onship with her partner will only become stronger if she has astronger faith in God .

Thi s vignette highli ghts the myriad ways in which Nana experiencedand treated both the illness , expressed through the diagnosis of bewit chment,and the disease of HIV, expresse d throu gh her dramatic weight loss anddiminished immune system. Nana concurred with the traditional healers'belief that she had been bewitched and this did not undermine the medicaldoctor ' s progn osis that she needed to start taking ARVs. In his study of theAzande , Evans-Pritchard ( 1937) described their dual theory of causation,which made an implicit distinction betwe en the how and the why of events.Thi s is in line with Green ' s (1994 ) distincti on between proximate and ultimatecauses of illness respectively. The ' how' relates to the ' proximate' cause ofdisease, for example, a child is ill becau se s/he has eaten food contaminatedby flies. The ' why' went into the local eschatology; it used empiricalobservation, and also the unseen or ' mystica l' factors at work such aswitchcraft. For exa mple, the flies were sent through witchcraft to contaminatethe child ' s food, causing the child to be ill. There was no contradiction inAza nde visiting a wes tern doct or to treat the manifest symptoms and stillbelieving that the rea l reason for the illness lay elsewhere (Evans-Pritchard,1937; Heald, 2003) . Th is is in line with Nana's multiple approaches to themanifest express ions and metaph ysical causation of her illness . In her

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understanding of HIV, she did not feel it necessary to choose between eithertraditional healing or biomedical care ; she used multiple forms of treatment atdifferent stages in her experience of the disease.

Nana ' s case study resonates with an international trend for HNpositive people to draw on a range of complementary, alternative andbiomedical treatment. Pawluch, Cain and Gillett (2000), for example,conducted a qualitative study in North America in order to assess 66 HNpositive people's decision to draw on a range of health therapies. They arguethat the interviewee' s deci sions to draw on complementary and alternativemedicines (CAM) relate to, amongst other things, a desire to mitigate the sideeffects of allopathic drug therapy and as a strategy for coping and maximisingquality of life. Furthermore, and in line with the argument made throughNana's case study, these authors argue that beliefs about and experiences ofhealth and illness significantly impacted the respondent's decision to accessCAM . However, Pawluch et al. (2000) assert that these beliefs and choicesare not mutually exclusive or fixed , and appeal to the respondents on differentlevels and at different times over the course of their life.

Nana ' s initial approach to healing her ailments were informed, in part ,by her social environment, especially her family , who encouraged her to seetraditional healers for healing. Howe ver , as discussed above, Nana came todistru st the people in her community (beyond her family) , and this eventuallyled to her moving to a different part of the country in order to avoid furtherbewitchments. The brute fact of continued ill health and severe weight loss,despite her work with traditional healers, motivated Nana to try an alternativehealth source: the clinic. In turn , her experience of taking antiretroviraltreatment has also shifted her understanding of HIV-related illness , as well asher belief that it is possible for HIV-positive mothers to give birth to HIVnegative children . Nana continues to access a range of alternative,complementary and allopathic health care services, but draws mainly onallopathic medicine to treat what she understands to be AIDS-relatedillnesses . Having considered the demand for a range of health servicesthrough the lens of Nana's case study, the following section moves on todiscuss a sample of traditional healer's understanding of illness and practicesof healing in relation to HIV and AIDS.

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Some Traditional Healers' Understandings ofIllness and Practices of HealingA striking aspect of Nana ' s case stud y relates to the belief that she was illbecause 'death ' and ' evil' had been ' put' into her body . Nana indicated thatthe traditional healers she visited viewed her healing as concomitant withpurging and removing this pollution and death from her body. The notion ofpollution as a cause of AIDS , and of illness in general, emerged as a dominanttheme in the interviews with the traditional hea lers that participated in thisstudy. In particular, the traditional healers spoke about getting the pollutionfrom the inside of the person 's body to the outside. Once the pollution was onthe outside, in the form of pimp les or (vagi nal/penile) disc harge , it could betreated topically.

Diso , a 35-year old woman who describes herself as a Chri stian and atraditional hea ler, believes that traditional medicine plays an important role incleansing HIY-positive peopl e 's bodies. She associates spiritual healing withChristianity, and defines it as using blessed ' holy water' to provide spiritualhealing and cleansing, on behalf, and in service, of God. Although she has notofficially trained to be a traditional healer, she der ives her knowl edge oftraditional medicines and healing through her dreams and communicationwith her ancestors . Diso said the following abo ut the role of traditionalmedicines in cleansing HIV-positive people's bodies of pollution:

(Traditional medicines) bring out the dirt (from) inside, they cleanse the inside.People who have HIV have a collection of diseases. So the moment they take intraditi onal medicines if the blood was dirty , they will first feel the itching on theoutside then they will develop big pimp les, have vaginal/penile dischar ge andthe eyes wi ll be stuffed with white discharge. The medicines clean se the wholebody and the client can see that. (Inte rview with Diso, 2005).

Diso's statement also indica tes the notion that sickness is moved fromthe inside of a person's body to the outside, through discharge, at which pointthe sickness can be topically treated and removed from the body. Similarly,the third traditional hea ler that Nana consulted ins isted that Nana's 'blackspots' marked the location where ' death and evil ' inhabited her body , andtherefore cut open these spots in order to remo ve the death from Nana's body.

Mng uni , an inyanga (is iZulu word for herba list) and trainer forinitiates, also believes in the value of moving the sickness out of his illclients ' bodies. In his work, Mnguni uses candles to facilitate divination, butsometimes he intuits the state of his client's hea lth when they ente r his

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consulting room: 'I feel it the moment the person step s in. I experience all hisor her feelings ' (Interview with Mnguni, 2003) . Mnguni , like Diso, did notundergo official training as an initiate, and also draws on his ancestors forknowledge about traditional medicines and healing practices. Both Diso andMnguni fulfil a number of roles that range from traditional healing to spiritualhealing, to divination and training of other initiat es who are entering thetraditional healing profession.

Like Diso , Mnguni argued that traditional healers need to cleanseHIV-positive people because only once one can see the sickness on theout side of the client' s body can the disease start to leave the body:

So when you as the healer are going to treat AIDS. you need to get somemed icine for him to cleanse and get rid of the inflammations. after that he/shewill get rid of the evil spirit. When that spirit is out, the sores or pimples willstart showing on the outside. Then you need to cleanse that person inside. Theperson must steam. After the patient has done that and the pimples and soresshow, he must continue using the medicin es to burn the sores. When the soreshave burn ed out you need to give him some topical medicines. (Interview withMng uni, 2005)

Aside from the belief that disease is a symptom of pollution inside theclient's body, there are also numerous understandings of the cause of HIV,and AIDS-related illnesses. Just as particular beliefs about illness influencedNana ' s choice of health care (and vice versa) , so too do they affect the mannerin which traditional healers treat their HIV-positive clients.

Mnguni 's approach to diagnosing HIV-po sitive people reflects hisbelief in the importance of clean sing for maintaining optimal health . Heargues that he can tell if a client is HIV-positi ve because he can feel that theirblood is cold , and can see that it is black . The latter is, according to Mnguni, asign of the presence of impurities in the blood. In addition to this form ofdiagnosis, Mnguni argues that one of the principl e causes of HIV relat es to theuse and behavioural implications of contraceptives like Depo Provera' .

The reason, the main cause of AIDS. if you recall in the olden days there wasnot as much prevention as we see these days. Many people usc preventi on, thatis the cause of the spread of this disease. Many people have become careless.They say no, I wo n' t get pregnant because I use the protective injecti on.(Interview with Mngun i, 2005).

Like Mnguni, Magagulu, a 38 year old male traditional healer ,belie ves that he is able to diagnose a person 's HIV-positive status during theirconsultation with him. Magagulu initiall y trained to be a spiritual healer, butunlike Diso, he rejected spiritua l healing in favour of traditional healin g after

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J40 HI V Illness Meanings and Collaborative Healing Strategies

he was advised through his dreams to become a traditional healer. This isperhaps re lated to the extensive training that he underwent , which took placeover 15 month s, in order to become formally recognised as a traditi onalhealer.

Magagulu shares Mnguni ' s belief that the use of Depo Provera is oneof the principle causes of HIV. However, in contrast with Mnguni , Magaguluhad a different understandi ng of why Depo Provera might facilitate HIVtran sm ission. Of particular interest, is the notion that this contracept iveencourages people to move away from ' traditional norm s' , which, accordingto Magagula, include women menstruating every month .

I suspect it 's because of the prevention that is used by wome n especia lly DepoProvera. I think it causes AIDS because it stops ovulation . It' s natural that theblood should come out so if that does not happen, its like ly to cause diseasesbecause I think that poison is very strong ... We have also talked about this inour workshops with THO (Traditional Healers Orga nisat ion) that AIDS iscaused by preventi on... . Something is not suitab le for you if its stops ovulationfor instance some people are abnormally big. That is the blood! It' s all over thebody because it does not come out. Some have bad varicose veins. It' s theblood that is all over the body. So I am trying to say contracepti ves are thecause of AIDS. (Interview with Magagu la, 2005) .

Magagula ' s assertion that women should menstruate each month issupported by his belief that women retain menstrual blood in their bodies and,because of this abnormal amount of blood, are therefore more susceptible tocontrac ting and transmitting HIV. In line with this asse rtion, Hendersonhighlights the asymmetry of pollution assignati on which often highl ights thewoman as the 'transmitter ' of pollution: ' the acknowledgement ofcontamination as a two-way proc ess demand s a sexual symmetry missing inpatr iarchal struc tures ' (2004: 19t Body fluid s, it should be noted, areunde rstood in different ways and are not necessarily viewe d as gener icpollutants. For example, Zulu epistemology attr ibutes value to women's bloodand men 's semen as creating and nurturing the growing embryo (Berglund,1976).

The biomedical searc h for a cure for HIV and AIDS is also reflectedin traditional healing practi ces. Mngun i said that his patients were despondentabout biomedical treatment of AIDS because they did not see clinics healingHIV-positive peopl e. Unlike medic al doctors, traditional healers can,according to Mnguni , offer a cure for HIV and AIDS. Given the traditi onalhealer' s conce rn to protect their knowledge, they were unwillin g to elaborateon or justify this assertion. Mnguni ' s belief that tradit ional healers can offer 'a

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cure for HIV and AIDS might relate to his perception that his clients are curedwhen their health improves. Curing illness, therefore, is measured throughvisual and experienced improvement in health, as seen by the traditionalhealer and reported by the client. The potential disjuncture betweenbiomedical and traditional practitioner ' s perceptions of ' cure' warrants furtherresearch as it has significant implications on the way in which HIV-positivepeople perceive the need for continuing with either, or both, biomedical andtraditional healing methods.

Like Mnguni, Magagula also believed that there is a cure for AIDSand HIV. He states:

I thin k besides using traditional medicines, I believe that there is a medical curefor AIDS but the government does not want to give it. What I am trying to sayis our government docs not care about black people. (Inter view with Magagula,2005).

In treating HIV-positive peop le, Magagulu first looks at their c liniccard to find out what stage the client is in. He believes that traditionalmedi cine is much stronger than allop athic medicine, and that it is notadvisable for ill HIV -positive peopl e to use traditional medicine as it mightmake them eve n more ill. If he can see that a client is going to die , or if hefinds them to be in the last stage of AIDS , he advises them to get treatment atthe local clinic . He is concerned that people with AIDS might die soon aftervisiting his practice, which would convey a message to his clientele that histreatment was potentially lethal.

In line with his belief that the government is withholding the AIDScure, Magagulu is also suspicious of government issued condoms, arguingthat health practitioners encourage condom use, even if the condoms havealready expired:

When you open these condoms, and it has exposed to air you find that it hasexpired and it has bugs and these bugs cause AIDS. The condoms that arc goodare the ones you buy from the chemist because they have done carefullybecause the manufacturers know they are going to benefit from sales. The onesthat are supplied by the gove rnment have done carelessly. I can say maybe it'sthe chemical they use on the condoms. Just like free contraceptives fromgovernment facilities causes problem s in peoples bodies. The rightcontraceptives you get are the ones you pay for. Sometimes if you arc literateyou can see from the packet that the medication or condom had expired. Butthe health practitioners tell you to use that medication. (Interview withMagagulu , 2005).

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142 HIV Il/ness Meanings and Collaborative Healing Strategies

Magagulu ' s distrust in government issued condoms raises a numberof potential problems in terms of HIV-prevention and opposition to the freecondoms that are aimed at preci sely those people who cannot afford to buycondoms.

Like Magagulu, Diso also believes in the value of knowing the HIVpositive client 's CD4 count in order to assess what kind of treatment toadminister because some forms of traditional medicine can be too strong foran HIV-positive 'person . In the interview Diso underlined the value oftraditional healers as counsellors; like Mnguni, Diso recognises that manypeopl e who come to her for heal ing are not only looking for medicine:

Some illnesses don ' t need to be treated by medicines, sometimes you justneed to talk to the client.. . To counsel them and ask what is bothering them forinstance the woman I said she told me that she was HIV positive I realised thatbesides being positive she was also depressed. I asked her about her problem.She opened up and said she was hurt because she was raped and it' s hard toforgive and forget about it. Sometimes you can see by looking at the clients orfeel what they feel. So some problems need the healer to sit and talk to clientsbut you also need to approach them in the right way. I told her to forgivebecause the person died and she was the one who was suffering. (Interview withDiso, 2005).

In addition to Disos assertion that clien t' s sometimes needcounselling for traumatic events or relationships, Diso belie ves that HIV canbe transmitted in a number of ways , many of which conform her belief thatillness is caused through evil spirits:

I don 't think people get the disease through sexual intercourse. I think there aredifferent ways that a person can be infected, through evil spirits not only sexualintercourse. Yes people get it through sexual intercourse, by dreaming abouteating because we sometimes dream about eating and you are actually beingpoisoned. By having wet dreams sometimes you do get infection. I think thereare opportunistic evil spirits that infect people with the disease. (Interview withDiso, 2005) .

As mentioned above, Diso describes herself as a Christian and as atraditional healer. Her belief that evi l spirits can infect a person with HIV iscontrasted with her con viction that an HIV-positive person can be cured ifthey are Christian:

I think people can be cured if they are dedicated Christians, they pray to God. Iam an example. .. . I don't think it' s a curse. Wc, the people, are failingsomewhere because there are people who get cured because they are convertedChristians... (Interview with Diso, 2005).

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Zima, a 55 year-old femal e tradit ional healer , concurs with Diso' sbelief that illnesses like HIV can be caused by evil spirits. Unlike Diso,howe ver, Zima is HIV-positive. Zim a said that she finds it difficult to belie vethat she could be HIV-positi ve because she describe s herself as healthy andfat:

It ' s confus ing, you can see that I am fat and healthy but found out that I haveHIV. I think our yo uth cannot see who has the virus because young men see acute and health y young lady, approach her and it happcns that the lad y is HIVposit ive and she does not d isclose her status. And our young men do notcondomise . TI1ey appreciate girls and want flesh to flesh, you see . (Interviewwi th Zima, 2005).

Additionally, Zima argues, HIV is a puni shment inflicted by ancestor sbecause of the move away from traditional values:

I thin k peopl e move d away from traditional way of life like, boys and girls can'tmain tain their virginity . In our times we did not have sexual interco urse .. .Those days yo ung men did it on thighs and never had vagina l intercourse. Thatpract ice was aba ndo ned by our children; they want flesh to flesh. I think thedisease, although I don ' t know how it ca me about, but I think that' s how it getssprea d. It' s a puni shm ent by ances tors because we aba ndoned our trad itionalways of life . It' s not wise these days eve n if a person is disci plined andce libate . A guy wo uld approac h her and, unknown to her, that is the guy w hohas the virus . . . (Inter view with Zima, 200 5).

Although both Zima and Diso ' s understanding of HIV and AIDSaetiology differs from biomedical descriptions of how HIV is tran smitt ed ,they advis e their clients to go to the clinic if their treatment has not yieldedsignificantly positi ve results . Additionally, Diso advises client s who shethinks ma y be HIV-positi ve to go for an HIV test. She claims that it isimportant for her to kno w what stage her client is in order to ascertain thestrength of the client's bod y. This in tum affects the kind of treatment that sheadministers to her HIV-positi ve clients.

In contrast to the abo ve-mentioned healers, Gogo (a female traditionalhealer who draws on bone-throwing and divination) and Ntswampi (a maletraditi onal healer who grew up in a famil y of traditional healers) belie ve thatHIV is not caused through failure to appease one ' s ance stor s or performcertain cultural rituals. In the course of the interview, Gogo (2005) said , ' If aperson is positive, s/he is positive. It has nothing to do with rituals.' Rhayi, a56 year old male traditional healer, asserts that HIV is a new disease and onewhich he cann ot treat because he does not know what the symptoms are. Hedoes, however, advocate collaboration between biomedical practitioners and

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trad itional healers in order for eac h group of healers to share their knowledgeand skills (Int ervie w with Rhayi, 2005).

Na na's perception of illness informed her decisions around accessinghealth care for both the psychosocial and physical aspects of the illness.Simi larly, the traditional healers' perceptions of illness played a role in theway they treated their clients. A significant aspec t of their treatm ent , which isa lso mirrored in Nana's case study, relates to the cleansing of polluti on fromtheir client s' bodies. Thi s form of treatment highlight s some of the tradit ionalhealers' perception that HIV is a pollut ant. Th is ' pollutant' could betransmitted by wo men ex periencing what the traditiona l healers describ e asexcessive blood reten tion because they did not menstruate eve ry month. HIVinfection was also attributed to HIV-posit ive clients' failure to appease theirances tors. The shift away fro m cultura l va lues that revere spiritual ances torsand adhere to strict sex ual codes of practice is perceived by Zim a to be apr inciple cause in the high rates of transmission of HIV. However,biomedic al exp lanations of HIV transmission are also drawn on by trad itionalhealers, like Gogo and Ntswa mpi. Th is understand ing of HIV also promptsthese healers to encourage their clients to draw on biomedical resources andtests in order to monitor the developm ent of the disease. The followin gsec tion draws on the tradit ional healers ' arguments arou nd the practic ali ties ofco llaboration in the light of current traditional heal ing practices and healthseeking behaviour that suggests the boundaries between biomedicine andtrad itional healing are fluid and in constant flux.

Exploring Networks of Collaboration in the Contextof South Africa's Public Health Care System

The most crit ical issue facing health care systems is the shortage of the peoplewho make them work . Altho ugh this crisis is greatest in developing countries,particularly in sub-Saharan Afr ica. it affects all nations. It severely constra insthe response to the AIDS treatment emergency and the develo pment of healthsys tems driven by primary health care, even as AIDS reduces the availa bleworkforce. (WHO, 2003 : 7).

As defined by the WHO (2003) prim ary health care is predicated oncommunity parti cipation, intersectoral health care approaches, universalaccess to care and co mmitment to health equity. In recogniti on of its inabilityto provide form al state health care to all those people who require it, SouthAfrica' s Department of Health (DOH) has advocated a Community and

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Home-based care (CSC and HS C respect ively) approac h to providingprimary health care (ANC, 200 I ). Tradit ional healers are included in theDOH ' s CBC polic y, but this commitment to the inc lusion and utilisation ofalternative health care providers like traditi onal healers is not necessarilyreflected in pract ice through policy impl ementation. Thi s section sketchesgovernment policy and pract ice regarding traditional healers and explores theperspectives of the interviewed trad itional healers on the value and possib ilityof more meanin gful co llaboration with the NHS within the field of HIV inSouth Africa .

South Africa's National Health Policy on HBC and CSC is supported(perhaps unwittingly) by a two-pronged arg ument. One aspect of theargument relates to the limited resources in the health care system, and theneed for informal orga nisa tions, co mmunity-base d carers and NGOs to fill' the void crea ted by neglect of health care needs in underserved populations.'(ANC, 1994 : 63). On the other hand , the arg ument refers to the gove rnment'sasse rtion that democracy should empower people to take care of their needsbecause it is ' undes irable, patronizing and promotes dependence if the statedoes it for them ' . (ANC, 200 I : 75). Thu s, in the contex t of post-I 994 SouthAfrica, community part icipat ion , including that of traditional healers, in healthcare is presented on the one hand as a ' so-ca lled' ex tension of democracy andon the other, as a viable alternative of care when the state cannot afford toprovide suffic ient health care for people dependent on state resources.

As with the two-pronged argument supporting the notion of ' care forthe community by the community', so too is there similar rat ionale support ingthe inclu sion of tradit ional healers in South Africa 's NHS. Minister of Health ,Dr Manto Tshabalala-Msimang, had the following to say in a closing remar kat the end of the First International Confere nce on Natural Products andMo lecular Therapy held at the Unive rs ity of Cape Town in January 2005 .

The study of Indigenous Knowledge Systems is not simply a scientificendeavour, but an opportunity to reclaim Africa's scie ntific and socio-culturalheritage wh ich was stigmatised and discredited as primitive rituals andwitc hcraft by co lonialism and apartheid. (quoted in Mngadi, 2005)

In shor t, the discourse supporting community-based care in general,and the inclu sion of trad itional healers as community health providers inparticular, is underpinned on the one hand by the dire need for informa l healthcare providers, and advocated on the other hand as ' democratic' and'empowering' to co mmunities that had been discriminated aga inst throughcolonialism and Apartheid.

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146 HI V JIIness Meanings and Collaborative Healing Strategies

In line with this bivariate rationale, the Department of Health (DOH)has developed a policy framework regarding the use of traditional andcomplementary medicines in South Africa. This framework includes theTraditional Health Practitioners Act and the National Drug Policy(www.doh.gov.za). The objectives of the Act are. to establish the InterimTraditional Health Practitioners Council of South Africa; to make provisionfor control of the regi stration, training and practices of traditional healthpractitioners in South Africa; and to serve and protect the interests ofmembers of the public who use the services of traditional health practitioners(Pefile , 2005) . A significant critique of this Act is that it does not proposeconcrete measures through which to implement its objectives. The NationalDrug Policy refers to the need to investigate trad itional medicines for safety,efficacy and quality with the aim to integrate their use into the NHS(www.doh .gov.za) .This is envisaged to be achie ved through: working moreclos ely with traditional healers to compile and develop a code of practice;establishing a National Reference Centre for African Traditional Medicines;and providing for the regi stration and control of marketed traditionalmedicines. In addition to developing the National Drug Policy, the DOH hasput R4.5 million into the Medicine Research Council 's Traditional Medicineunit to facilitate the testing of the components and efficacy of varioustraditional medicines (Pefile, 2005) .

Each of the traditional healers that were interviewed in this studyargued strongly for collaboration between the traditional healers andbiomedical practitioners. Their reasoning was predicated on their belief thatthese forms of healing were not necessarily exclusive, and that some aspectsof the illness , and the disease, of HIV were better treated by either traditionalhealers or biomedical practitioners or a combination of both. This reasoning issupported by Nana' s case study which highlights the fact that a range ofhealing professionals can address different aspects of HIV and AIDS . This isfurther exemplified in Magagula 's statement below:

The person who has motivated me is Manto, Tshabalala. She has spoken infavour of tradit ional healers and said there is a need for traditional healers anddocto rs to work together to curb the AIDS pandemic . Yes, there are manydiseases that need a dual treatment from doctors and traditional healers. And itdepends on what kind of illness is being treated. As I practice here, I know thatthere are people who are sick and those that are not sick, they just have personalproblems that need to be attended to. So with sick people, there are illnesses,for instance, traditional healers do not have a drip.

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What I see as a shortfall in South Africa or amongst us traditio nal healers, wenee d to work toge ther and form an organisation. When we are organised wecan invite the department of health. I think we can gain some thing fromworking with them beca use there are illnesses that need to be treated by bothdoc tors and traditional healers. I said there are people who need a drip beforetaking traditi on al med icine or we can give our homemade drip like water withsa lt and sugar as we were told , to give them energy, ( Interview with Magagula,2005) .

Gogo, a trad itional healer who works primarily with people who havecancer, AIDS and mental illness es, also referred to the value of a drip inorder to counteract malnutrition and dehydration :

. . . tradit ional healers don 't have drips. Sometimes the client is dehydratedbeca use of diarrh oea so they need to go to clinic to a drip. Then the patient canbe boosted by drip only. (Interview with Gogo, 2005) .

Magagulu also asse rts that the government has failed South Africansbecause if they had involved traditional healers in its respon se to HIV earli er,the traditional healers could have intervened faster to contro l HIV. He arguesthat the Tradition al Healers Organi sation (THO) has trained traditi onal healersto impart knowledge of HIV and prevent ion to their client s, and they havealso provided traditional healers with knowledge about HIV and A IDS-relatedillnesses and ways of labelling and preserving their medicines:

The THO showe d us how to treat a person who has diarrhea which is a problemin areas where people get water from the stream. They to ld us . . . to educate ourclie nts that they sho uld boil or purify the water before consumption. The y alsotaught us abo ut AIDS . At that time condom use was fairly new; there werepeople who were taught how to usc a condom, they came back anddemonstrated to us so that we could educate our c lients. We were also taughtabo ut hygiene and cleanliness . Every traditi onal healer should keep hisworki ng place clean . We also talked about some traditio nal healers who pileup their medici nes and do not label them. To know what medicine it is theysmell or chew it, we were told that was not acce ptable. We need to label ourmedi cines so that we don't con fuse them .

THO taught about cond om use, how to use a drip, about AIDS and its causesand about clea nliness . They told us that whi te people are not in favor ofwork ing with healers who use certain anima l parts to make medicines. Ifsomeo ne used animal parts he/she should find a place far away from otherpeople. So, they emphasised on clea nliness , there are people who use animalbones and sometimes they smell bad. That 'could also cause diseases, so we aretalking about cleanlin ess, they emphasise d that some one who is working withpeopl e needs to be clean. So they said you must three different working areas,like exa minatio n roo m, treatment room and storage for your medicines.Because of the lack of space and money it's not feasible to have these threeplaces, there are few people who can afford that. (At this point Magagula

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pointed to his she lves of med icine in the roo m in which the interview wastak ing place) .. . But cleanliness is very important and I think before you leaveyo u can have a look at my medici nes that side to make sure what I am talkingabo ut. ( Interview with Magagula, 2005)

Magagula ' s statement above indicates an awa reness and willingnesson behalf of the THO to train traditi onal heal ers to conform to particularstandards of hygiene and medica l practice, including teac hing clients how topurify wat er to prevent diarrhoea and how to use condoms to reduce HIVtransmission. This statement also co ntrasts with the views expressed byMagagula and Mnguni in the above section in which Depo Provera wasaccorded responsibility for high rates of transmission . This raises a numb er ofquestions that can and perhaps should be explored in future research. Firstly,Depo Provera may be thought to be dangerous because it might deter womenfrom using condoms wi th their partn ers. A second interpretation is that thesetraditi onal healers condone condoms used by men but do not believe thatwo men should use oral or injected contracepti ves because it interferes withtheir ability to bear childre n.

Aside from the THO' s enco urage ment of tradit ional healers toeducate their clients about HIV, the benefit s of co llaboration are articulatedand advocated through the DOH ' s 'continuum of care ' model, the NationalDru g Policy, the Tradit ional Health Practiti oners Ac t and the e Be policy.However, concrete steps have not been taken by the state to implement thi slegisl ati on . Perhaps this relates to what Homsy, King, Ten ywa, Kyeyune,Opio and Balaba (2004) describe as distrust by clinical professionals oftraditional healers and traditional medi cine. Thi s may also relate to the factthat some traditional healing practices operate outside the rat ional legalparadigm in which biomedicine acts, which in turn may inform clinicianspercepti on that that traditi onal healers do not have sufficient information totreat HIV-positive people. It is argued that traditional trea tments have

never been rigorously eva luated, arc not always properly prepared orstandardized, and arc freque ntly poorly packaged and preserved, limiting theirusefulness and access ibility to the immediate production site (Rukangira, 200 Iin Hom sy et al., 2004 : 905).

Efforts, however, have been made by traditional and complementaryhealers in Africa to establish regulations regarding traditional healer ' streatment of HIV-positi ve people. For exa mple, a Ugandan NGO, Traditionaland Modern Health Practitioners Together against AIDS and Oth er Diseases(THETA) , spearheaded a regional initi ative to define the standards of practice

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regarding the involvement of traditional healers and traditional medicine inHIV and AIDS prevention , care and treatment. These standards represent thefirst regional and participatory attempt to boost the validity and credibility ofAfrican traditional healing while seeking to maintain its diversity. THETAcalls for rigorous testing and evaluation of traditional medicine,standardisation of traditional healing practices with HIV-positive people, andthe provi sion of education, counselling and referral sources to HIV-positi veclients. (Homsy et aI., 2004).

The drive to include traditional healers in HIV education, preventionand treatment programmes has also been taken up some NGOs and e BOs inSouth Africa. For example, the AIDS Foundation of South Africa partneredup with local traditional healer associations and launched an HIV/A IDStraining program for traditional healers. In the period 1995-200 I, over 6000traditional healers were trained through this programme to disp el myths thatpropagate stigma, to identify sign s and symptoms of HIV , to observe infectioncontrol procedures, to promote HIV and AIDS education in their communitiesand to establish formal referral networks with medical clinics and hospitals(www.aids.org.za).This example illustrates the range of services thattraditional healers can offer HIV -positi ve people who visit them for palliativeand psychosocial care . The se training programmes are not implementedthroughout South Africa, but only through a small number of organisationscommitted to moving the HIV health agenda, as set out by the government,forward through participatory programmes with traditional healer s.

However, it should be noted that collaboration between these twohealth care paradigms should not entail a seamless mapping of one onto theother. The biomedical assumption, highlighted by some of the abovementioned programmes that encourage collaboration, that traditional healersare useful only if they conform to and work within an overarching biomedicalframework is also problematic. Green (1994) explores the dynamics ofpotential collaboration between traditional healers and biomedicalpractitioners in Southern Africa, and suggests the relative value of each ofthese practices asserting the importance of noting disjuncture as well ascorrelation between these healing paradigms. For example, Gre en note s thattraditional healers are sought out for treatment of sexually transmitteddiseases, which if treated correctly, can drastically reduce the chances oftransmitting or contracting HIV through unprotected sex (1994). Furthermore,as indicated through the analysis of Nana's treatment strategies, various

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heal ers are drawn on in order to heal the psychosocial and physical aspect s ofthe illness and disease of HIV respectively. Na na's case study also point s tothe complementarity and difference between traditi onal and biomedicalhealin g paradigms. Thi s paper asserts that while it is useful to explore routesof collaboration between traditional healers and biomedicine, particularly inthe field of HIV, it is also important to recognise that these healing paradigmsalso have different qualiti es to offer HIV-positi vc people.

In addition to the above ca ution regarding co llaboration, formalisationof trad itional healin g practices as a precondition for co llaboration betweenbiomedical practitioners and trad itional heal ers can potentially create ahierarchy of HIV health care options that are form ally sanctioned by the state.Thi s hierarchy already exists between different groups of health careproviders, and collab orat ion will not necessaril y address or underm ine thi sdeeply entrenched hierarchy. Furthermore, some of the traditi onal healers whoparti c ipated in this study also sugge sted that there is value in prioritisingbiomed ical treatment ove r traditi onal medi cine, particularly when the clientwas in the last stage of A IDS, or if their health had not improved followingthe traditional healers ' treatment. Some traditi onal healers, like Magagulu, feltthat the doct ors were perceived to be more ' legi timate' because of their formalrecognition by the state as medic al healers:

The reasons people go to doctors is that they want to know if the disease isunder control or not, no matter they feel pains or no pains. If we can beregistered as we have planned in the workshops in Johannesburg, we plannedthat iNyangas should be given their time to work with AIDS patients to givethem tradit ional medicines in the hospital wards. (Interview with Magagula,2005)

According to Magagulu traditional healers often play a role in theHIV -positi ve patien t' s recovery, but becau se the patient uses numerou smethods of health care, including clinical treatment , the doctor does notnece ssarily recogni se the traditional heal er ' s work. In his view, this can serveto perpetuate the hierarchy of biomedi cal practitioners over traditional healersin the field of HIV diagnosis and treatm ent:

We (tra ditio nal healers) work in the dark beca use most of the time the patientscome to me and go to hospital. When the person gets better the doctor who hasattended the patient wi ll get a promotion while the patients used traditionalhealin g as well. . . . The doctors asked them what they have been taking. Whenthey tell the doctors about traditional medicines they would say, ' nonsense whydid you use witchdoctors' medicines ' . They arc treated bad ly and told not to

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usc our medicines. And AIDS patient s don 't have the courage to defendthemselves. (Interview with Magagula, 2005).

The above statement also indicates Magagulu ' s distrust of medicaldoctors and his belief that HIV-positive clients are treated badly by theirdoctors if they acknowledge that they are using traditional medicine. Whetheror not this is the case, Magagulu ' s statement underlines the fact that ahierarchy of healing practices exists in which the clinician is at the pinnacle,under which traditional healers, complementary health care practitioners andthe ill client fall (but not necessarily in this order, see Baer, Singer andJohnson, 1986).

Magagulu ' s statement also indicates frustration with the medicalprofession for dismissing the contribution of traditional healers by falselyconflating traditional healers with ' witchdoctors '. Similarly, Diso believesthat one of the main reasons why traditional healers are not taken seriously bythe biomedical profession is because of their association with witchdoctors,This may be a result of what Green (1986, in Wreford, 2004) describes as theequation of traditional healers with witchdoctors through the intentionalmisapplication of the latter term to traditional healers by missionaries in theearly years of colonialism. In mo st cases , however, traditional healers assertthat they are only connected with witchdoctors insomuch as they areresponsible for healing the 'witchcraft' inflicted through witchdoctors ' work(Green, 1986 and Niehaus, 2001 , in Wreford, 2004) . Magugulu 's frustrationwith doctors' conflation of traditional healers with witchdoctors is underlinedby Wreford, who suggests that doctors may use the term ' witchdoctor' tolegitimate their own misunderstanding of traditional healers; the negativeassociations connected with ' witchdoctors ' maybe used by doctors to justifytheir disrespect or dismissal of traditional healers. The dismissal of'witchcraft ' , and the concomitant traditional healers who are drawn on inorder to heal bewitchment, poses a significant challenge to biomedicine:

If biomedicin e continues to prefer ignorance, it may have to accept that patientswill continue to take thc unfini shed business of their illnesses, the moralconcerns whi ch underpin them, to a sangoma, for only there will they receive' real' healin g. (Wreford, 2004: 5).

Aside from the distrust that permeates the relationship betweendoctors and traditional healers, a distrust of the South African governmentemerged as a strong theme in the interviews. Broadly speaking, this refers tointellectual property rights around traditional medical knowledge. The DOHovertly acknowledges the value in 'reclaiming Africa's scientific and socio-

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cultural her itage ' through the study of so-ca lled ' indigenous knowledgesystems'. However, the issue of sharing and owning ' indigenous knowled ge 'remains a contested issue, particularly in relation to the Medical ResearchCouncil ' s testing of potent ial ' indigenous' medicinal plant s for treatingcertain HIV-related illnesses. Ntswampi, for example , feels that thegovernment is trying to find out about the components of their medicine,without recognising their right to be recognised as valuable partners in healthcare provision in South Africa :

I have seen some programmes on TV that on one side there is some help andthe other side the healers are sabotaged .. . what we don' t wa nt is to be cheatedbecause we are going to tell them about our medicines, they are going to writethem down, but they are not going to tell us what antiretrovira ls are made of.(Interview with Ntswampi, 2005).

Like Ntswa rnpi, Diso argues that it is unfair that the gove rnment hasstarted to use and recommend the African potato without ackn owledging thegenea logy of traditi onal healers ' knowledge of African medicinal plants andherbs. Thi s sugges ts that collaboration is not necessarily viewe d as havingpositi ve outcomes for each of the healing professions, but that sharingknowledge , and subsequent success , may be unidirection al, favouringbiomedicine.

In addition to a concern over intellectual ownership of 'i ndigenous'medicinal solutions, the traditional healers expressed a belief that thegovernment is not committed to providing non-di scriminatory health care toall South Africans regardless of race:

The gove rnment said they don 't have money to pay those (pharmaceutical)companies, so that indicates that the govern ment docs not care about us.Diseases that affect black people arc sometimes taken seriously and sometimesnot. Yes, we have many other needs and the government is overpowered, buton the issue of AIDS I see that the government does not care enough. Somepharmaceutical companies have reduced their prices, for instance there is a pillthat initially cost R200 each but now it costs R50. So they are trying to fightAIDS. ... In the previous government there was never a disease that killed somany people like this. These days the majority of people that are dying areblacks and very few whites are dying. If AIDS was killing many whites itwou ld have been curbed long ago. (Interview with Magagula, 2005).

It is noteworthy that Magagulu feels that if the HIV epidemic affectedwhite people to the same extent that it affects black people, it would havebeen more directly and quickly addressed . Perhaps this belief is part of theresidue of Apartheid's discriminatory health care, or perhaps this statementreflects dissatisfaction with the current government's approach to address ing

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the HIV-epidemic. Additionally, Diso argues that the current government'sapproach to treating HIV-positi ve people does not take into account thepractical limitations of providing biomedicine, like ARV s, to destitute HIVpositi ve people . Diso insists that the government find ways of incorporatingfood distribution into their antiretrovira l roll-out in order to enhance theefficacy of antiretrov irals. The following statement also highlights Diso 'sawareness of the range of factors that contribute towards healing HIV-positivepeople beyond traditional or allopathic medicines:

I think the government is lacking in a big way because what' s happ enin g is thatwe are faced with unempl oyment. In the first place peopl e wi th HIV/AIDS donot get nourishment. People need health y food and the disabili ty grant take slong. People get it when there are less chanc es of surviva l. I think that thegovernment is lacking because people don't have jobs and they are sic k. Thereis no support like food to nouri sh the body with . Some of the people I treat , Isee sometimes that the y need food. I think the government is not supportive.Even if people take antirctroviral. you cannot takc medicines on an emptystomach or you are goin g to vomit. What are they goin g to eat '? (Intervi ew withDiso, 2005).

In addition to Diso, a number of traditional healers pointed out thatantiretroviral therapy and some of their own treatments are renderedredundant when the treatment is not taken with food . Thi s further underlinesthe value of holistic and collaborative approaches that move beyondbiomedicine in order to provide maximal health care to HIV-positive people.As highlighted abo ve, the traditional healers interviewed in this study assertedthe importance of providin g holistic treatment to their clients. Examples ofthis form of holi stic treatment ranged from incorporation of biomedicalpractices, like encouraging seriously ill patients to attend the clinic for dripsor other treatment rather than taking their medicine, to insisting on theimportance of practical support , like food , in the administration of the ARVroll-out and of their own medicines, to the value of psycho social support, likecounselling.

The views expressed by the traditional healers in this study resonatewith the observed practices of traditional healers involved in a studyconducted in Hlabisa that explored the incorporation of traditional healers intoa tuberculosis directly observable treatment (DOT) control programme.Between 1999 and 2000 in the three study sub -districts, 53 patients (13%)were supervised by traditional healers and 364 (87%) were supervised byclinic health workers or lay people .

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154 HI JI Illness Meanings and Collaborative Healing Strategies

Overall. 89% of those supervise d by traditional healers co mpleted treatment,compared with 67% of those supervised by others (P = 0.002). The mortalityrate among those supervised by traditi onal healers was 6%, whereas it was 18%for those supervised by others (P = 0.04) . Interestingly, none of the patientssupervised by traditional healers transferred out of the district duri ng trea tment,while 5% of those supervised by others did. (Co lvin, Gumede, Grimwade andWilkinson , 200 1: N.P)

High levels of satisfaction were reported by the patients supervised bytraditional healer s, with all of the patients stating that traditional healersshould be involved as supervi sors for future DOT programme s. A majo radvantage, according to these patients, was that the traditional healers wereeasi ly acc essible because they typic ally lived near to the patient. Thi s issupported by Green ( 1994) who argues that traditi onal healers may also bevisited mor e frequentl y because they live locall y and may be more familiarwith a client ' s soci al context than doctors and nurse s working in a clinic .Oth er reason s for sati sfaction, according to Colvin et 01. (2001), related to thetraditional healers ' caring attitude and concern about the genera l well being ofthe patient they supervised. One patient stated: ' They love their patient s andtreat them like family' . Th is approac h was also demonstrated by threetrad itional healers doing regular home visits to eighteen pat ients in the earl yphase of their treatment because the patients were too ill to leave their homes.Three pat ients in the study sa id that they had regularly received food fromtheir supervisor during treatment consultations (Co lvin et 01., 2001).

Qoli , a traditional healer who participated in the study for this paper ,exemplifies the possibility of co llaboration between tradit ional andbiomedical healers. She works as a patient advocate with a team of cliniciansinvolved wi th the antiretrov iral roll out in Langa, a town ship in the WesternCape. Qoli describes how , in 1996, she became seriously ill and visited atraditional healer for treatment. This meeting, she said, was 'like an electricalconnection between me and my background - where my roots were comingfrom.' During this meeting she reali sed that it was her destiny to becom e atraditional healer , and proceeded to undergo training in Mpumalan ga in 1999.She describes her work as a patient advocate as ' hands on healin g' , andbelieves that she can integrate her knowledge of traditional healing with hercommitment to care for the people starting ARVs through the Langa clinic .

Like Qoli , Mnguni believes that alth ough collaboration may bedifficult, and sometimes unnecessary, there is a lso potential for positiveoutco mes for HIV-positi ve clients. He sugges ts the following plan:

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I have a requ est. I don't know how the government can help us. My request is,if the gove rnment wa nts to see AIDS control and treatment, they must not askfor the cure . They must refe r AIDS patients to us, they must give us tenders totreat and cure AIDS pat ients. Th ey must give us fixed quotas of patients: theymust ask us how long we are going to take to treat these people. We would tellthem and do as we pro mised. (In tervie w with Mnguni, 200 5).

Ntswampi suggests that the gove rnment provide a hospital in whichboth medical and tradit ional healers work; he arg ues that this would faci litatebetter co mmunication, and greater health care provision for the patients.Similarly , Rhayi regard s collaboration as possible, and beneficial to theclients :

I don 't think we cann ot work together if we can negotiate and reach certainagreements, I th ink if we can work together we ca n control diseases . We canlearn from each other, so I belie ve if we can share info rmation we can protec tmany people . . . Med ical doctors are good because they gained expertknowl edge through learnin g about diseases. The y are good and can be helpfulin certain things we don ' t know and we can also help them with things theydon ' t know. (Inter view with Rhayi, 2005).

As men tioned above , distrust of tradit ional healing is not unfounded ;the traditi onal healers themselves argue that witchdo ctors and untrainedpeople pretending to be traditi onal healers undermine the positive andvaluable function that trad itional healers perform. Addit ionally, they suggestthat their knowledge of HIV is limited , and state unamb iguously in theinterviews that they wo uld like to receive more tra ining aro und HIV,However, as discussed above, co llabora tion does not infe r the mapping oftraditional healin g onto biomedical pract ices, or vice versa , but should allowfor places of divergenc e where each can offer relati ve and different resourcesto HIV-positive clients . As argued above , research with traditi onal healers andthe HIV-positive clients, point s to the importance of conside ring the value andpracticaliti es of collaborative health care networks, while acknow ledging thatboth biomedic al and traditional pract itioners offer independent , andsometimes overlapping, forms of care that address both the illness and diseaseexperi ences of HIV-posit ive peopl e. Thi s paper recognises the fact that arange of traditional healin g practices exist in South Africa, and that similarly,all tradi tional healers do not necessaril y share the views of the traditionalhealers represented in th is pap er,

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156 HI V!IIness Meanings and Collaborative Healing Strategies

ConclusionThe high number of traditi onal healers combined with a rapidly increasi ngHIV-ep idem ic in South Africa points to the value of researching illnessmean ings and healing strategies employed by both traditi onal healers andHIV-positi ve people in this co untry. Na na' s case study highli ghts the value ofa more nuanced understand ing of HIV: one that recogn ises the psychosocialand also the material aspects of HIV and AIDS-related illnesses, and theform s of health see king behaviour that are developed in response to theseaspects of HIV and A IDS. The traditi onal healers who part icipated in thisstudy offe red a range of beliefs around HIV causa tion and treatm ent ,emphas ising the range of beliefs that can be held under the broad term of' traditiona l healing' .

The theme of pollut ion emerged throughout the interviews,highli ghting the perc eption that HIV can be caused through contact withpo llution, and that it can similarly be cured throu gh cleansing the HIVposit ive individual and bringing the pollution to the outside in the form ofpimples or vagina l/penile dischar ge. Significantly, the traditional healers drewon and incorporat ed biomedical ind icators of disease, like the CD4 count, anddemonstrated a knowledge of the trajectory of HIV illness as show n throughthe various stages of disease defin ed by WHO and used in South Africa'spubl ic health care system. Distru st in the gove rnment also emerged as anoteworth y theme in the subsequent section on collaborative possibilit ies andlimitat ions between traditi onal healing and biom edicine. On the one handman y of the trad ition al healers advocated collaboration between themselvesand doctors and nurses, and on the other hand , biomedical sta ff were viewe dwith distru st. Thi s was particularly evi dent in the traditional healers'insis tence that knowledge sharing should be mutually beneficial, and that thetraditional healers ' kno wled ge of various medicines should be form allyac know ledged by medical bodies like the Medi cal Research Council in SouthAfrica.

Th is paper therefore argues that South Africa ' s legal and politicalrhetoric, which recognises the importance of incorporating traditional healersin the public health sector, be matched with a greater degree of empiricalresearch into the practicalities and limitations of co llaboration betweentraditi onal and biomedical healin g practices. This is particularly importantgiven the escalating rates of HIV-infection in South Africa, and the limitationsof South Africa's biomedical health care services in treatin g this growing

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HIV-population. Additionally, the nuanced nature of HIV, as a psychosocialillness and a biological disorder, plays a significant role in the health caredecisions made by HIV-positive people and their fami lies; this, in tum, callsfor greater attent ion to be paid to the multiple and overlapping healingstrategies developed by HIV -positi ve people, and supported by health carepractitioners in South Africa. Following the se recommendations, the shiftingterrain of Sout h Africa ' s health care system is likely to undergo furthertransformations that will , with careful consideration of the interconnectionbetween the se healing paradigms, facilitate more effective and vital healthcare for people living with HIV and AIDS-related illnesse s in South Africa.

Elizabet h Mills holds an Honours degree in Social Anthropo logy from the Universityof Cape Town and is currently completing her Masters degree in Developm entStudies at the University of Cambridge. Her research interests include gender andHIV, transitional j ustice, human security and the impact of the global polit icaleconomy on access to HIV and AIDS treatment. Her emai l address isbeamill [email protected] .

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Notes

The author is grateful to Busi Magazi for the significant contribution that she hasmade to this paper through her work as the assis tant researcher on this project.

These settlements are characterised by high unemployment and low incomes. This islargely a result of the residue of Apartheid laws that encouraged the development of a

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cheap non-white labour force on the periphery of central business and industrial areas(Wilson and Mafeje, 1963; Magubane, 1979).

This perception might relate to Apartheid's misuse of this contraceptive in responseto the perceived threat of black women 's fertility. In many cases it was administeredin an autocratic manner and without counseling or the full consent of the womeninvolved (see http://popdev.hampshire.edu/projects/dt/dt32.php#_edn24 and http://shr.aaas.org/Ioa/pviod.htm accessed in 2006).

This theme is also reflected in Ratele and Shefer's (2002) description of how womenare accorded blame for transmitting HIV to their male partners.

Rigorous testing of traditional healers and medicine in South Africa is contested issuein South Africa . Commitment to rigorous testing is evinced by the award of R4million to the Medical Research Council in South Africa from the Department ofHealth. However, the minister of Health has also supported certain forms oftraditional medicine, like the African potato, without insisting that it be scientificallytested (www.tac.org.za; www .doh.gov.za).

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HIV Illness Meanings and Collaborative Healing Strategies in South Africa

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